Coroner's Finding: SHUEARD Braydon Adrian

60y · Male·Sepsis due to pressure ulcers due to immobility on a background of advancing frontotemporal dementia, diabetes and ischaemic heart disease

A 60-year-old man with frontotemporal dementia, diabetes, and ischaemic heart disease died from sepsis secondary to pressure ulcers while subject to a Mental Health Act inpatient treatment order. He developed sacral and heel pressure injuries while immobilised at a residential facility, despite appropriate preventive measures including repositioning, alternating pressure mattress, and wound dressing protocols. The ulcers became infected and he deteriorated rapidly, requiring hospitalisation where he received surgical debridement and medical management before transitioning to comfort care. The coroner found the care at both the residential facility and hospital to be appropriate, with no deficiencies identified. This case highlights the challenges of managing immobilised patients with complex psychiatric and medical comorbidities, and the difficulty of preventing pressure ulcers in those with advancing dementia and significant medication-induced sedation.